Stopping Preventable Infections in Dialysis

It is now one year since Nephrologists Transforming Dialysis Safety (NTDS) began its work. The Centers for Disease Control and Prevention (CDC) awarded the American Society of Nephrology (ASN) 3 years of funding to sponsor NTDS, as part of its effort to improve infection-control practices in dialysis facilities across the United States.

The critical need to eliminate preventable infections in dialysis is shown in the dialysis databases. The PEER Report (2014) demonstrates only modest improvement in the rate of patient admission for infection between 2004 and 2014.

The USRDS 2016 Annual Data Report (vol 2, ESRD, Ch 5) shows hospitalization rates for dialysis patients, indicating that while all-cause and cardiovascular hospitalization rates have been declining from 2005 to 2014, hospitalization for infection has not improved substantially

The 2014 PEER Report, “Cause of death in prevalent dialysis patients” shows that infection causes 9.5% of all deaths (1).

For several years, the CDC worked with dialysis companies to promote evidence-based best practices and useful tools to prevent bloodstream infections (BSI) and hepatitis C virus (HCV) infections. The NTDS project aims to more directly involve nephrologists as team leaders and as professional role models to reduce the burden of BSI and other healthcare-related infections in dialysis patients.

Building upon the foundational principles of the CDC’s Making Dialysis Safer for Patients Coalition, the NTDS project is aimed at transforming dialysis care, to make infection prevention part of the fabric of everyday care for dialysis patients. The specific project aims include:
  1. Adhere to CDC-recommended infection prevention practices

  2. Screen and detect infections

  3. Implement clinical protocols to ensure accurate detection and treatment of infections

  4. Facilitate collaboration between nephrologists and state/federal healthcare-associated infection programs

Figure 1.

Annual & quarterly admission rates—infection as the primary discharge diagnosis

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Figure 2.

Adjusted all-cause and cause-specific hospitalization rates for ESRD patients by treatment modality, 2005–2014

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Year one achievements

NTDS believes that ending preventable infections requires a cultural change in dialysis facilities—where daily infection prevention is a priority, where caregivers and patients accept accountability for their part in stopping infections, and where a culture of safety encourages sharing and reporting of safety practices in a community that welcomes opportunities to correct and improve daily performance. Cultural change requires thoughtful planning and stakeholder input. In year one, NTDS successfully reached out to decision-makers across the nephrology community to incorporate their insights into the work of the Project Committee and Workgroups.

We then devised an implementation plan to determine best strategies for infection prevention and to garner feedback from the community on useful tools for leading improved practice. We led community meetings and focus groups to identify specific infection-control practices, barriers, and opportunities. We performed a root-cause analysis exercise among NTDS members, and augmented those insights during ASN’s Kidney Week 2016. Contributing to this effort were 737 physicians, researchers, nurses and nurse practitioners, pharmacists, physician assistants, other healthcare professionals, and trainees. Barriers to infection prevention that were identified included lack of education and training; lack of policies, protocols, and procedures; absence of data; presence of central venous catheters; lack of leadership; and lack of governmental collaboration. NTDS synthesized these wide-ranging views, and developed a roadmap to guide each workgroup’s activities. To support this work, NTDS launched a robust set of online resources. We created a series of NTDS webpages within ASN’s website that includes a resource library of infection prevention tools.

One important objective was to prepare for the unknown. When the Ebola epidemic reached into the US, including the need to prevent infection spread during dialysis care, it became clear that the dialysis community needed to quickly learn new and critical methods for isolation, spent dialysate disposal, bloodline management, and possible Ebola exposure among our chronic dialysis patients. We were unprepared as a community to manage such virulent infection, and those few nephrologists who faced the challenge needed to deal with these challenges “on the fly.” We want to be better prepared for the next epidemic. To this end, NTDS conducted a gap analysis to identify lessons learned by speaking with the nephrologists who managed the few cases of Ebola that required dialysis treatment in the US.

To reach a broad audience of dialysis caregivers, we launched an educational series, including webinars, regional lectures and interactive seminars, and seminars at ASN’s Kidney Week. The first webinar, attended by nearly 500 nephrologists and other professionals, was titled “Targeting Zero Infections: Where Do We Begin?” This case-based conference stressed several key educational points, including the virulence of hepatitis C, the role of the nephrologist as a leader, and direction to the online resource library. Almost 100% of attendees found the webinar content useful and anticipate participating in Webinar 2, “Targeting Zero Infections: Combating Blood Borne Pathogens,” scheduled for September 27, 2017. For ASN’s Kidney Week 2017, NTDS will conduct several activities, including an Early Program seminar titled “The Dialysis Infection Crisis in the United States: A Call to Action,” and a presentation during the annual meeting, “Infection Prevention: Are You Prepared for the Next Ebola?”

Engaging those who will make a difference to care requires a multi-dimensional approach. NTDS has established a presence on several communication platforms, including:
  1. Website URL: https://www.asn-online.org/ntds. This includes a resource library highlighting current topics, including data and quality improvement, identification and treatment of bloodborne pathogens, regulations, and leadership and culture

  2. Facebook, administered by ASN: https://www.facebook.com/AmericanSocietyofNephrology: Posts including ASN President’s invitation to the NTDS Town Hall, links to Kidney News Online articles, promotions for the NTDS website, and information about NTDS webinars

  3. Twitter administered by ASN: Hashtags: #ASN_-NTDS and #targetzeroinfections.

  4. NTDS Community in ASN Communities: highlights have included NTDS Town Hall, regular glove use vs. sanitizer use, ClearGuard HD Antimicrobial Barrier Cap, and anti-infection or infection resistant surfaces.

If infection control practices are to become part of the fabric of daily dialysis care, the next generation of nephrologists and leaders will need robust education and practice patterns. NTDS identified several education and training needs:
  1. Incorporate current guidelines: policies, procedures, and protocols

  2. Fellow’s Curriculum: infection prevention and leadership education and training

  3. Hand hygiene

  4. Human factors engineering, continuous quality improvement, and best practices

  5. Credentialing

  6. State/Federal healthcare-associated infections (HAI) program introduction and mandates

Antibiotic stewardship has been deployed in hospitals, but is not generally part of dialysis facility operations. These efforts improve outcomes in several ways. When antibiotics are administered only when there are clear indications for their use, fewer patients harbor antibiotic resistant organisms or develop multiple antibioti–resistant infections. Tailoring antibiotic administration to the agent appropriate for the organism and type of infection reduces the pressure on organisms to develop antibiotic resistance. In addition, it is now becoming clearer that the health-promoting gut microbiome can be permanently altered by multiple courses of antibiotics. Antibiotic stewardship reduces unnecessary exposure to antibiotics, and better preserves the normal gut microbiome. Dialysis patients are often prescribed courses of antibiotics, including wide spectrum agents. Antibiotic stewardship programs in dialysis facilities have the potential to substantially reduce unnecessary exposure of patients to these antibiotics.

NTDS identified several leadership mandates to facilitate. We will succeed only if we collaborate closely with dialysis organizations. We have engaged the leadership of the large and medium-sized dialysis companies, and seek ways to work together to enhance lines of communication, enhance training for medical directors, identify dialysis facility infection control leaders/coordinators, and collaborate with state/federal HAI programs and renal organizations. We also seek to reduce inconsistencies among government agencies and eliminate knowledge gaps between dialysis facilities and governmental HAI programs.

Year two plan

For the coming year, NTDS will continue to expand our education and physician engagement activities, present a series of articles in Clinical Journal of the American Society of Nephrology, complete and share a curriculum for trainees and medical directors to stop preventable infections, complete and share a guideline for anticipating and preparing for emerging threats, and encourage collaboration between dialysis professionals and state/federal HAI programs. In addition, NTDS will work with dialysis facilities to develop and refine programs to transform the dialysis culture to a culture of safety and individual accountability. By engaging nephrologists, dialysis facility owners, and other stakeholders in these many transforming activities, NTDS believes we can get to our target of zero preventable infections.

Disclaimers

Peer Data: The data reported here have been supplied by the Centers for Medicare & Medicaid Services and the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government. The Peer Kidney Care Initiative has no affiliation with the US government.

USRDS Data: The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government.

"September 2017 (Vol. 9, Number 9)"

Reference

1. Cause of death in prevalent dialysis patients: Peer Dialysis Initiative, Peer Report: Dialysis Care and Outcomes in the United States, 2014.